Early childhood disparities spur medicine’s call to action

The preponderance of research demonstrates that children from the lowest rungs of the socioeconomic ladder are at the greatest risk for health deficits, and the disparities are especially stark when it comes to the cognitive development of newborns to 3-year-olds.

Citing this body of evidence at its most recent meeting, the AMA House of Delegates adopted a “call to action” in the form of a policy acknowledging “the role of early child brain development in persistent educational and health disparities.” The new AMA policy encourages “public and private stakeholders to work to strengthen and expand programs to support optimal early childhood brain development and school readiness.”

Pediatric experts interviewed for this article concurred with the AMA’s recommendations.

“There is a strong correlation between the likelihood of cognitive impairment and the lowest of household incomes,” said Louis J. Kraus, MD, professor and chief of child and adolescent psychiatry at Rush University Medical Center. “The most common reasons for impairment are environmental intrauterine traumas, including poor nutrition and prenatal care, and fetal exposure to alcohol and drugs.”

In addition, Dr. Kraus pointed out, many children from the poorest homes in America lag behind in language acquisition, a major determinant of normative cognitive development. “If your family is struggling to put food on the table and pay the rent, they may not have time to read ‘Goodnight Moon’ to you,” said Dr. Kraus, former chair and member of the AMA’s Council on Science and Public Health.

Poverty’s developmental impact

Another cause of disparities in early childhood brain development, noted Benard Dreyer, MD, is a phenomenon called “toxic stress,” a condition precipitated by chronic strain brought on and aggravated by continued economic hardship.

“Toxic stress can change your hormones and other systems that interfere with your ability to both learn and behave appropriately,” said Dr. Dreyer, director of the developmental-behavioral pediatric division at the New York University School of Medicine and immediate past president of the American Academy of Pediatrics. “Children with toxic stress always feel threatened and are always on edge.”

The complications associated with cognitive development are often exacerbated, said both physicians, by the lack of intervention at an early age. They and other authorities agree that if children’s lags in cognitive development are not addressed by age 3, they most likely will suffer from impairment throughout their lifetimes. “Once you have cognitive deficits, you have cognitive deficits,” said Dr. Kraus.

Cognitive impairment in children is difficult to reverse because of physiologic changes that occur in young children’s brains, said Dr. Dreyer. “On average, these children have smaller volume and surface areas of the brain,” he said. Most affected, he added, “are the temporal lobe, which controls language; the frontal lobe, which controls executive function; and the hippocampus, which controls memory—all the abilities that you need to succeed academically.”

The social costs to lifelong cognitive impairment are enormous, said Dr. Dreyer. Children whose cognitive impairments are not addressed—or are addressed too late—have “a much higher high school dropout rate, poor social and emotional development, higher levels of drug and alcohol use, and higher rates of juvenile delinquency,” he said. “It puts them on the trajectory for intergenerational poverty.”

Added Dr. Kraus: “Sixty to 70 percent of people in the criminal justice system have a learning need.”

The American Academy of Pediatrics has a policy describing the pediatrician’s role in optimizing school readiness through attention to patients’ physical, social and emotional well-being, as well as their cognitive and linguistic development.

Drs. Kraus and Dreyer said that there are concrete ways physicians and their practice team members can help address the issue of lagging cognitive development brain development in poor children. They recommend:

Learning about food support and other social programs in your community so that you can connect appropriate families to needed services.

Encouraging qualified families to enroll their children in early intervention programs such as Head Start, and helping them to find such offerings.

Educating parents and parents-to-be about do’s and don’ts during pregnancy: no smoking, alcohol consumption and recreational drug use—and a big yes to diets rich in protein, fiber, iron and B vitamins.

Offering programs in your practice that enhance child development, such as Reach Out and Read.

Advocating more services that promote the well-being of poor families, such as school meal programs, universal preschool, and maternal and child health programs.

In its action in November, the AMA described giving all children access to “a quality public education, including early childhood education, as one of the great unmet health and civil-rights challenges of the 21st century.”

“The more we can do in the beginning to shape a child’s future,” said Dr. Kraus, “the better for the child,” the family and the entire community.

Comments

In the wake of the water problems in Flint, Michigan, the Community Foundation has received funding from donors to address the exact "toxic stress" referenced above. By providing age 0-5 early support, we are hoping we can minimize the effect this crisis has had on our kids. Thanks for the article.
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